DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
671671 A. BUILDING __________
B. WING ______________ 		09/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AMARA HOSPICE 505 WEST OWASSA ROAD, EDINBURG, TX, 78539
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0671      
36596 Based on record reviews and interviews, the agency failed to ensure that the clinical records were current, complete and accurate for 1 of 1 patient (#1) whose clinical record was reviewed, in that: The Hospice Skilled Nurse (HSN) incorrectly documented a medication order for a high-risk medication by omitting the dosage. The This failure to comply with resulted in Patient #1 being put at risk of harm and substandard care. The Findings Included: During Pre-Survey on 09/28/21 at 03:35 p.m. the Surveyor reviewed complaint intake #305855, it was dated as received on 09/28/21. It read in part: "The Complainant stated that RN A left medications at Nursing Facility 1 (NF1). These medications included Morphine and that RN A left a handwritten note with the orders for Morphine but did not include a dosage for Morphine on the note." Review of Patient #1's clinical record included a Plan of Care (POC) for the certification period starting on 09/21/21, that listed a primary terminal diagnosis of Congestive Heart Failure. The POC listed a HSN visit frequency as two times a week and two as needed visits a week (PRN). Continued review of Patient #1's clinical record revealed pre-printed standard hospice medication orders signed by the physician and dated 09/22/21. The correct order for the Morphine on the pre-printed orders read as follows: "Morphine Sulfate 20 mg/ml, 0.5 ml PO/SL every 3 hours PRN for Pain/SOB/Cough 7-10." The meaning of the order was as follows: the Morphine Sulfate is in a concentrate of 20 mg's Milligrams (mg) per milliliter (ml) and that dosage for Patient #1, was 0 .5 ml, by mouth (PO), sublingually (under the tongue [SL] ) every 3 hours as needed (PRN) for pain, shortness of breath (SOB) or cough that caused pain on a pain scale of 7 to 10. Continued review of Patient #1's clinical record obtained from NF 1 revealed a "Physician's Telephone Orders" form. It read in part: Agency Name, Agency Address, Patient Name, Patient Room Number, Patient's Physician's name and was signed by RN A and dated 09/22/21. There were six medication orders handwritten on the Physician's Telephone order form. The first one was Morphine. The handwritten order read as follows: "Morphine Sulfate 20 mg/ml, q 3 hours PRN for pain (7-10)." The order did not contain a the dosage of .5 ml PO/SL. Contnued review of the handwritten order revealed 0.5 ml written on the left outside margin of the order, it was lined through, barely legible and had no initials. During an interview with RN A conducted on 09/30/21 at 08:07 a.m., RN A was made aware of the findings in Patient #1's clinical record. She stated that she did hand write the medication orders on the physician's telephone form even though there were already pre-printed orders that had a correct order for Morphine and she agreed that the handwritten order for Morphine was not a complete and accurate way to document a medication order and agreed that the clinical record was not correct. Review of the Agency's Policy and Procedure Manual revealed a policy titled "Medication Administration", it was numbered TX.17 and had a revision date of 06/01/15. It read in part: "Procedure - ll. Written physician's order specify: A. Patients name, B. Medication Name, C. Medication Dose, D. Medication route, E. Frequency of medication administration; if prn, indication for use is required and F. Medication start date/time, and G. Medication stop date/time when appropriate."
L0679      
36596 Based on clinical record review and interview, the hospice failed to ensure all patient record entries were legible, clear and complete, authenticated and dated in accordance with the hospice policy for 1 of 1 patient (#1) whose record was reviewed. Patient #1's clinical record included an incomplete documented medication order for a high-risk medication by omitting the dosage. This failure prevents the agency from ensuring patient medications and services are provided as ordered, coordinated effectively and places Paitent #1 and all active agency patients as risk of harm. The Findings Include: Review of Patient #1's clinical record included a Plan of Care (POC) for the certification period starting on 09/21/21, that listed a primary terminal diagnosis of Congestive Heart Failure. The POC listed a HSN visit frequency as two times a week and two as needed visits a week (PRN). Continued review of Patient #1's clinical record obtained from NF 1 revealed a "Physician's Telephone Orders" form. It read in part: Agency Name, Agency Address, Patient Name, Patient Room Number, Patient's Physician's name and was signed by RN A and dated 09/22/21. There were six medication orders handwritten on the Physician's Telephone order form. The first one was Morphine. The handwritten order read as follows: "Morphine Sulfate 20 mg/ml, q 3 hours PRN for pain (7-10)." The order did not contain a the dosage of .5 ml PO/SL. Contnued review of the handwritten order revealed 0.5 ml written on the left outside margin of the order, it was lined through, barely legible and had no initials. During an interview with RN A conducted on 09/30/21 at 08:07 a.m., RN A was made aware of the findings in Patient #1's clinical record. She agreed to the following facts: - RN A did hand write the medication orders on the physician's telephone form. - RN A agreed that the handwritten order for Morphine was not a complete and clear way to document a medication order. Review of the Agency's Policy and Procedure Manual revealed a policy titled "Medication Administration", it was numbered TX.17 and had a revision date of 06/01/15. It read in part: "Procedure - ll. Written physician's order specify: A. Patients name, B. Medication Name, C. Medication Dose, D. Medication route, E. Frequency of medication administration; if prn, indication for use is required and F. Medication start date/time, and G. Medication stop date/time when appropriate."
L0781      
36596 Based on record review and interview the agency failed to enforce it's written policy that specified the agency's client care practices in that: The Skilled Nurse failed to immediately report and document a medication error. The failure to comply with accepted professional standards written in the Agency's policy resulted in a delay in care and placed Client #1 at risk of harm and substandard care. The Findings Included: During Pre-Survey on 09/28/21 at 03:35 p.m. the Surveyor reviewed complaint intake #305855, dated as received on 09/28/21. It read in part: "The Complainant stated that RN A from the Hospice Agency, left medications at Nursing Facility 1 (NF1) for Client #1. These medications included Morphine and that RN A had left a handwritten note with the orders for Morphine but did not include a dosage for Morphine on the note. At 04:30 a.m. on 09/23/21 the Nursing Facility Nurse (NFN) #1 noticed the handwritten medication note and without notifying the Hospice or Client #1's Physician gave Client #1 20 milligrams (mg) of Morphine. At 07:00 a.m. on 09/23/21 the NFN #1 called RN A to verify the dosage. Neither nurse took action by contacting a supervisor or filling a medication error report. Client #1 died on 09/24/21 at 03:19 p.m." Review of Client #1's clinical record from NF 1 revealed a "Physician's Telephone Orders" form. It read in part: Agency Name, Agency Address, Client Name, Client Room Number, Client Physician's name and was signed by RN A and dated 09/22/21. There were six medication orders handwritten on the Physician's Telephone Order form. The first one was Morphine. The handwritten order read as follows: "Morphine Sulfate 20 mg/ml, q 3 hours PRN for pain (7-10)." The order did not contain a dosage. Further review of the Client #1's clinical record form NF 1 revealed the following entry: - NFN #1 gave 20 mg/s of Morphine at 04:31 a.m. on 09/23/21. Continued review of Client #1's clinical record revealed pre-printed standard hospice medication orders signed by the physician and dated 09/22/21. The order for the Morphine on the pre-printed orders read as follows: "Morphine Sulfate 20 mg/ml, 0.5 ml PO/SL every 3 hours PRN for Pain/SOB/Cough 7-10." This is the correct order and dosage for Morphine. Further review of the communication notes in Client #1's clinical record failed to show that a Hospice Agency Supervisor had been notified of the medication error as soon as it was disclosed to RN A. During an interview with the ADM/DON on 09/29/21 at 01:44 p.m. the Surveyor requested that the Administrator identify the form that the Agency uses to document Occurences and Incidents. The ADM/DON identified a Hospice Agency form titled "Patient/Employee Occurrence/Incident Report." Still Further review of Client #1's clinical record failed to include a Hospice Agency form titled "Patient/Employee Occurrence/Incident Report" for the date that the incident occurred (09/23/21). During an interview conducted on 09/30/21 at 08:07 a.m. RN A agreed to the following facts: - RN A received a call from NHN #1 on 09/23/21 at 07:30 a.m. - During that call NHN #1 asked RN A about the correct dosage for Morphine, and informed RN A that she had given Client #1 20mg's (1 ml.) of Morphine (an overdose). (Mayo Clinic defines Overdosed as the following: "A drug overdose is too much of a substance, whether it's prescription, over-the-counter, legal or illegal. If more than the prescribed or recommended amount of a drug is given or taken, it is an overdosed ...") - RN A confirmed that as of 07:30 a.m. on 09/23/21 she was aware of the Morphine medication error. - RN A confirmed that she did not immediately notify a Supervisor or Client #1's Physician. - RN A confirmed that she did not write an Occurrence/Incident Report. Review of the Agency's Policy and Procedure Manual revealed a policy titled "Medication Administration" numbered TX.17 with a revision date of 06/01/15. It read in part: XI - "The attending Physician and the Agency Supervisor will be notified regarding any medication errors as soon as possible." Further review of the Medication Administration policy read in part: XIV - "Any Medication error or adverse reactions will be documented on the "Occurrence Report" and submitted to management immediately."